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Original Articles • Rev. Saúde Pública 50 (suppl 2) • 12 Dec 2016 • https://doi.org/10.1590/S1518-8787.2016050006161 copy

Access to medicines for chronic diseases in Brazil: a multidimensional approach

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To analyze the access to medicines to treat non-communicable diseases in Brazil according to socioeconomic, demographic, and health-related factors, from a multidimensional perspective.

METHODS

Analysis of data from the National Survey on Access, Use and Promotion of Rational Use of Medicines (PNAUM), household survey, sampling plan by conglomerates with representativeness of the Brazilian population and large areas of the country, according to sex and age domains. Data collected in 2013–2014 with sample of adults (≥ 20 years) who reported having non-communicable diseases and medical indication for use of medicines (n = 12,725). We assessed the prevalence of access to medicines for self-reported non-communicable diseases, considering four dimensions: availability, geographic accessibility, acceptability, and affordability. We applied Pearson’s Chi-square test to assess the statistical significance of the differences between strata, considering the level of significance of 5%. We found prevalence of 94.3%, 5.2%, and 0.5% for full, partial, and null access, respectively. Higher prevalence was observed among seniors in the South compared to the Northeast; for those who reported having one non-communicable disease compared to those who reported having two or more; for those who needed one medicine compared to those who needed three or more; and for those who self-assessed their health as good or very good. Geographic accessibility was similar in the Unified Health System and in the private pharmacies (72.0%). Total availability of medicines was 45.2% in the Unified Health System, 67.4% in the Popular Pharmacy Program, and 88.5% in private pharmacies. Acceptability was 92.5% in the Unified Health System, 97.8% in the Popular Pharmacy Program, and 98.7% in private pharmacies. As to affordability, 2.6% of the individuals failed to take the medicines they should in the 30-day period prior to the interview due to financial difficulty. Prevalence of full access to medicines for non-communicable diseases in Brazil is high and presents significant differences for age group, region of the country, number of non-communicable diseases, and for medicines prescribed and self-assessment of health. The major barriers to access to medicines were identified in the dimensions analyzed.

Adult; Aged; Drug Utilization; Chronic Disease; Socioeconomic Factors; Health Surveys

Variable	Prevalence of access to medicines for NCD

	Full		Partial		Null		p^b

	%^a	95%CI	%^a	95%CI	%^a	95%CI
Sex							0.025
Male	95.6	94.3–96.6	3.9	2.9–5.2	0.5	0.3–0.9	-
Female	93.6	92.4–94.6	5.8	4.9–7.0	0.6	0.4–0.8	-
Age group (years)							< 0.001
20-39	91.2	87.5–93.8	7.5	4.9–11.3	1.3	0.8–2.3	-
40-59	93.5	92.2–94.6	5.8	4.7–7.0	0.7	0.5–1.1	-
≥ 60	96.2	95.3 –96.9	3.7	3.0–4.6	0.1	0.04–0.1	-
Educational level^c							0.032
0-4	95.1	93.9–96.0	4.4	3.5–5.5	0.5	0.3–0.9	-
5-8	95.1	93.7–96.3	4.5	3.4–5.9	0.4	0.2–0.7	-
9-11	92.6	90.7–94.2	6.8	5.2–8.7	0.6	0.3–1.1	-
≥ 12	95.1	92.7–96.7	4.3	2.7–6.6	0.7	0.3–1.6	-
Region							< 0.001
North	93.6	91.1–95.4	4.7	3.2–6.9	1.7	0.9–3.2	-
Northeast	92.0	90.2–93.5	6.8	5.4–8.6	1.2	0.8–1.9	-
Southeast	94.9	93.4–96.1	4.8	3.7–6.4	0.3	0.1–0.6	-
South	95.8	94.4–96.9	3.9	2.9–5.2	0.3	0.1–0.8	-
Midwest	93.9	92.2–95.2	5.8	4.5–7.3	0.3	0.1–0.8	-
CCEB^d							0.004
A/B	96.4	94.7–97.5	3.2	2.1–4.9	0.4	0.1–1.0	-
C	94.1	93.0–95.1	5.5	4.5–6.6	0.5	0.3–0.7	-
D	92.8	90.5–94.6	6.1	4.5–8.3	1.1	0.6–2.0	-
E	90.8	85.3–94.3	8.7	5.2–14.2	0.5	0.2–1.4	-
Number of NCD							< 0.001
1	96.7	95.7–97.5	2,5	1.8–3.5	0,7	0.5–1.1	-
2	93.5	91.7–94.9	5,9	4.6–7.6	0,6	0.3–1.1	-
≥ 3	91.3	89.7–92.8	8,5	7.1–10.1	0,2	0.1–0.4	-
Number of medicines needed^e							< 0.001
1	97.0	95.7–98.0	2.7	1.8–4.0	0.3	0.1–0.6	-
2	94.4	92.7–95.7	5.5	4.2–7.2	0.2	0.04–0.7	-
3-4	94.2	92.4–95.5	5.8	4.5–7.6	-
≥ 5	91.1	88.4–93.2	8.9	6.8–11.6	-
Self-assessment of health							< 0.001
Very good/Good	96.5	95.5–97.3	3.1	2.3–4.1	0.4	0.2–0.7	-
Regular	93.2	91.8–94.3	6.2	5.1–7.6	0.6	0.4–1.0	-
Bad/Very bad	86.8	83.6–89.4	12.4	9.8–15.5	0.8	0.4–1.8	-
All	94.3	93.4–95.1	5.2	4.4–6.0	0.5	0.4–0.7	-

Variable	Geographic accessibility to pharmacy services

	SUS pharmacy		Popular pharmacy		Private pharmacy

	%^a	95%CI	%^a	95%CI	% ^a	95%CI
Sex	0.007^b		0.064^b		0.165^b
Male	75.3	71.4–78.8	70.8	65.6–75.6	73.9	70.3–77.1
Female	70.7	67.9–73.4	65.5	61.3–69.4	71.7	68.9–74.3
Age group (years)	0.057^b		0.151^b		0.110^b
20-39	67.4	61.7–72.6	60.0	50.0–69.3	68.3	62.5–73.7
40-59	74.1	70.5–77.3	68.5	63.5–73.0	73.3	69.9–76.4
≥ 60	72.0	68.6–75.3	68.1	64.4–71.6	73.2	70.5–75.8
Educational level^c	0.597^b		0.643^b		0.898^b
0-4	71.8	67.6–75.6	69.3	64.4–73.8	73.2	67.9–76.2
5-8	73.2	69.6–76.4	65.6	59.8–71.0	72.6	68.3–76.6
9-11	71.2	67.7–74.6	66.3	60.9–71.3	71.8	68.5–74.8
≥ 12	74.7	69.3–79.4	66.8	58.9–73.7	72.2	66.7–77.1
Region	0.012^b		0.005^b		0.140^b
North	59.5	53.5–65.3	54.3	47.0–61.4	69.4	64.2–74.1
Northeast	74.4	69.8–78.5	61.1	54.9–66.9	69.6	64.5–74.3
Southeast	71.6	66.8–75.9	70.8	64.8–76.1	75.2	70.5–79.3
South	77.1	73.0–80.8	69.4	63.4–74.8	71.3	66.2–75.9
Midwest	67.0	61.1–72.4	59.1	51.5–66.4	68.3	62.4–73.7
CCEB^d	0.162^b		0.001^b		0.001^b
A/B	75.4	71.1–79.2	73.7	67.6–79.0	77.8	74.0–81.3
C	72.2	68.9–75.3	65.8	61.4–69.9	71.3	68.2–74.1
D	68.7	63.1–73.7	57.6	50.5–64.5	65.7	60.1–70.8
E	74.4	63.4–82.9	80.2	67.4–88.8	72.8	61.3–81.9
Number of NCD	0.455^b		0.002^b		0.021^b
1	73.1	68.9–76.9	72.8	68.5–76.7	74.5	71.1–77.6
2	72.6	69.4–75.6	65.3	60.0–70.2	73.0	69.7–76.0
≥ 3	70.7	67.4–73.8	63.1	57.7–68.2	68.9	64.8–72.8
Number of medicines needed^e	0.001^b		< 0.001^b		0.001^b
1	77.3	72.5–81.4	72.0	65.9–77.4	75.8	71.7–79.4
2	73.2	69.1–77.0	74.5	68.9–79.3	76.2	72.6–79.6
3-4	73.0	69.3–76.3	66.9	61.7–71.7	71.7	68.4–74.7
≥ 5	67.6	63.9–71.1	59.9	53.8–65.7	68.1	63.7–72.2
Self-assessment of health	0.001^b		0.001^b		0.001^b
Very good/Good	74.6	70.6–78.2	73.3	69.7–76.5	76.4	73.6–79.0
Regular	71.9	68.9–74.6	62.7	57.6–67.5	69.7	66.3–73.0
Bad/Very bad	62.6	57.4–67.6	58.0	49.6–65.9	64.4	59.0–69.4

All	72.3	69.5–74.9	67.3	63.7–70.7	72.4	69.7–74.9

Variable	Percentage of availability of medicines needed^e

	SUS pharmacy		Popular pharmacy		Private pharmacy

	%^a	95%CI	%^a	95%CI	%^a	95%CI
Sex	< 0.001^b		0.294^b		0.810^b
Male	50.0	46.0–54.0	69.2	64.7–73.4	88.7	86.3–90.8
Female	42.7	39.6–45.9	66.4	62.9–69.7	88.4	87.0–89.7
Age group (years)	0.456^b		0.017^b		0.166^b
20-39	46.5	40.0–53.0	59.1	49.0–68.5	85.9	80.9–89.7
40-59	43.8	40.3–47.3	71.6	67.1–75.6	89.5	87.8–90.9
≥ 60	46.2	42.6–49.9	65.5	62.1–68.8	88.6	87.2–89.9
Educational level^c	0.923^b		0.226^b		0.133^b
0-4	45.8	41.4–50.2	64.7	60.4–68.7	87.9	86.1–89.5
5-8	45.5	40.9–50.0	70.8	65.3–75.8	90.3	88.0–92.1
9-11	44.4	40.6–48.2	69.1	64.6–73.3	89.3	87.2–91.1
≥ 12	46.1	40.1–52.2	67.4	59.5–74.5	85.8	81.0–89.6
Region	< 0.001^b		< 0.001^b		0.000^b
North	41.7	36.0–47.5	71.7	63.6–78.6	88.6	85.8–91.0
Northeast	31.6	27.9–35.6	54.3	48.4–60.0	82.7	79.4–85.6
Southeast	51.8	47.1–56.5	68.1	63.4–72.5	91.1	89.4–92.5
South	45.8	41.9–49.8	74.5	70.0–78.5	89.6	87.4–91.4
Midwest	33.0	28.5–37.9	72.1	66.6–77.0	87.7	85.3–89.9
CCEB^d	0.499^b		0.594^b		0.719^b
A/B	44.2	39.9–48.7	68.8	63.4–73.7	88.6	86.3–90.6
C	45.7	42.4–49.0	67.5	64.1–70.7	88.8	87.5–90.1
D	45.7	40.6–50.8	65.9	59.0–72.2	88.0	84.9–90.6
E	38.5	29.9–47.9	58.6	40.7–74.4	85.0	72.0–92.6
Number of NCD	< 0.001^b		< 0.001^b		0.042^b
1	56.6	52.4–60.6	74.1	70.2–77.7	90.0	88.4–91.4
2	41.7	37.9–45.6	67.5	62.5–72.1	87.9	85.8–89.8
≥ 3	32.6	29.4–35.9	60.5	55.9–64.8	87.2	85.0–89.1
Number of medicines needed^e	< 0.001^b		< 0.001^b		0.633^b
1	57.2	52.4–61.8	75.6	70.5–80.0	89.4	87.4–91.1
2	47.4	43.4–51.4	69.1	63.1–74.5	88.7	86.6–90.6
3-4	41.2	37.7–44.8	65.0	60.0–69.7	87.8	85.2–90.0
≥ 5	29.4	25.3–33.8	57.6	52.5–62.6	87.8	85.1–90.0
Self-assessment of health	< 0.001^b		< 0.001^b		0.322^b
Very good/Good	54.0	50.3–57.6	72.9	69.1–76.5	89.3	87.5–90.8
Regular	39.0	35.9–42.1	63.5	59.6–67.3	88.1	86.3–89.6
Bad/Very bad	30.3	26.1–34.8	56.8	48.6–64.7	86.9	83.3–89.9

Full	45.2	42.2–48.2	67.4	64.4–70.2	88.5	87.3–89.6

Variable	Acceptability to the pharmacy services

	SUS pharmacy		Popular pharmacy		Private pharmacy

	%^a	95%CI	%^a	95%CI	%^a	95%CI
Sex	0.589^b		0.601^b		0.500^b
Male	92.6	90.5–94.2	98.1	96.7–98.9	98.5	97.7–99.1
Female	92.1	90.5–93.3	97.7	96.4–98.5	98.8	98.3–99.2
Age group (years)	0.008^b		0.390^b		0.386^b
20-39	91.1	87.1–94.0	95.0	88.4–98.0	98.3	96.6–99.1
40-59	90.8	88.9–92.4	98.3	97.2–99.0	98.6	97.8–99.1
≥ 60	94.0	92.6–95.2	98.1	97.1–98.7	99.0	98.5–99.4
Educational level^c	0.678^b		0.077^b		0.660^b
0-4	92.7	91.0–94.0	98.3	97.2–99.0	98.5	97.7–99.0
5-8	92.5	90.3–94.0	98.2	97.1–98.9	99.2	98.6–99.6
9-11	92.1	89.6–94.0	96.5	93.7–98.1	98.6	97.6–99.2
≥ 12	90.7	86.7–93.6	98.8	96.4–99.5	98.8	97.7–99.4
Region	0.001^b		0.001^b		0.413^b
North	84.2	80.0–87.7	88.9	84.2–92.4	97.1	95.4–98.2
Northeast	88.8	86.4–87.7	96.3	94.3–97.7	98.3	97.4–98.9
Southeast	93.4	91.0–95.2	98.5	96.6–99.4	98.9	98.3–99.8
South	95.1	92.9–96.7	99.0	96.4–99.5	99.4	98.3–99.8
Midwest	90.0	86.4–92.7	98.6	96.4–99.5	98.5	97.0–99.3
CCEB^d	0.814^b		0.781^b		0.466^b
A/B	92.9	89.3–95.4	98.1	96.4–99.0	98.9	97.9–99.4
C	92.3	90.6–93.7	97.7	96.3–98.6	98.8	98.3–99.2
D	91.3	88.8–93.3	97.5	95.6–98.6	98.3	96.8–99.2
E	92.1	83.9–96.3	98.6	95.6–99.6	97.1	90.5–99.2
Number of NCD	0.104^b		0.237^b		0.075^b
1	93.3	91.5–94.7	97.3	94.9–98.3	98.6	97.8–99.1
2	91.0	90.5–94.7	98.4	97.3–99.1	99.1	98.4–99.5
≥ 3	91.8	89.7–93.6	98.2	96.3–99.2	98.6	97.8–99.1
Number of medicines needed^e	0.948^b		0.531^b		0.075^b
1	92.3	89.5–94.4	97.3	95.3–98.4	98.5	97.4–99.1
2	92.3	89.9–94.2	97.5	93.6–99.0	98.0	96.3–98.9
3-4	92.6	90.6–94.3	97.8	96.1–98.8	98.8	98.1–99.2
≥ 5	91.9	89.9–93.6	98.6	97.6–99.2	99.3	98.7–99.6
Self-assessment of health	0.001^b		0.168^b		0.142^b
Very good/Good	98.4	97.5–99.0	98.4	97.5–99.0	99.0	98.2–99.4
Regular	90.3	88.0–92.2	97.3	95.6–98.3	98.3	97.7–98.8
Bad/Very bad	92.2	90.8–93.4	97.3	94.1–98.8	99.2	98.2–99.6

All	92.2	90.8–93.4	97.8	96.9–98.5	98.7	98.3–99.0

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